What To Do When Your Doctor Has Bad News

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Medicare Doesn’t Equal Dental Care. That Can Be a Big Problem

“Many people view Medicare as the gold standard of United States health coverage, and any attempt to cut it incurs the wrath of older Americans, a politically powerful group. But there are substantial coverage gaps in traditional Medicare. One of them is care for your teeth. Almost one in five adults of Medicare eligibility age (65 years old and older) have untreated cavities. The same proportion have lost all their teeth. Half of Medicare beneficiaries have some periodontal disease, or infection of structures around teeth, including the gums. Bacteria from such infections can circulate elsewhere in the body, contributing to other health problems such as heart disease and strokes. And yet traditional Medicare does not cover routine dental care, like checkups, cleanings, fillings, dentures and tooth extraction… Adding a dental benefit to Medicare is popular. A Families USA survey of likely voters found that the vast majority (86 percent) of likely voters support doing so. The survey also found that when people do not see a dentist, the top reason is cost. Ms. Willink’s study estimated that a Medicare dental benefit that covered three-quarters of the cost of care would increase Medicare premiums by $7 per month, or about 5 percent. The rest would need to be financed by taxes.” (New York Times)

Medicare Problems

The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.

Every year it fields thousands of calls from people having problems with their Medicare. In its latest report summarizing calls from 2016, it grouped problems into three areas: 1) Medicare Part B enrollment rules and pitfalls; 2) difficulties with Medicare Advantage (MA) health service denials and coverage rules; and 3) financial hardship affording Medicare Part D cost-sharing.

Here’s a typical case: “Ms. B was covered by COBRA and undergoing cancer treatment. She declined to enroll in Medicare Part B because her employer incorrectly told her COBRA would pay as a primary health insurance payer after she went out on disability. While receiving expensive life-sustaining cancer treatment, the COBRA plan stopped paying primary and recouped a year of payments. Ms. B was left without health insurance, charged for thousands of dollars in medical bills, and threatened by providers to cut off her cancer treatment because she lacked insurance coverage for outpatient services.”

The report points out something we’ve been seeing for years, and which inspired our creation of the Savvy Medicare Planning program in the first place: knowing when to enroll in Medicare falls on the beneficiary without proper notification from the Social Security Administration or Medicare. And many employers’ benefits departments lack the Medicare knowledge to guide their employees and retirees on Medicare enrollment. “Whether due to the misinformation provided by employers or lack of access to reliable information about Medicare enrollment, enrolling in Medicare Part B at the right time after employer coverage ends is a challenge that many people can get wrong. Contributing to the problem is the lack of a formal notice about enrolling in Part B or how to use the Part B Special Enrollment Period (SEP), as well as a misunderstanding of Medicare’s coordination of benefits rules when people have other types of health insurance coverage,” the report says.

One area many people get wrong is the special enrollment period that allows people age 65 or older to defer enrolling in Medicare Part B if they have employer coverage. The coverage must be based on current employment of self or spouse; it can’t be a retiree plan. Medicare pays primary to retiree plans—but only if a person is enrolled in Medicare. Medicare also pays primary to COBRA—but again, only if you are enrolled in Medicare. “People with retiree coverage or COBRA who fail to enroll in Medicare will end up without a primary health insurance payer. In some cases, people may slip through and go unnoticed while the secondary health insurance erroneously continues to pay primary. Some beneficiaries explain that they are informed of this employer error only after they have incurred high medical costs. When this happens, Medicare-eligible beneficiaries run the risk of the insurer recouping all payments made to providers.”

The bipartisan BENES Act would improve Medicare notification procedures and fix the coverage gaps in the 5th, 6th, and 7th months of the initial enrollment period and in the January 1 to March 31 general enrollment period, which now makes new enrollees wait until July for coverage to start.

Another area of concern are Medicare Advantage coverage denials. These comprised about 40% of the 16,758 calls to the Medicare Rights helpline. In one case a woman experiencing gastrointestinal bleeding went to the emergency room of an in-network hospital where she was treated by an out-of-network doctor. The plan refused to pay for the doctor’s services because he was not in the network. This was not an isolated case. There were many complaints from Medicare Advantage enrollees who were careful to use in-network facilities where, unbeknownst to them, they were treated by out-of-network doctors.

Medicare Advantage enrollees also have trouble accessing needed care in their plan’s network because the pool of network specialists is limited and may result in long waiting periods for appointments. One person near Portland, Oregon, for example, had to wait up to four months to get an appointment with a dermatologist in her plan’s network to remove cancerous skin tissue. Medicare Advantage plans all have an appeals process, but navigating it is a stressful and onerous task.

About 20% of calls expressed concern about Medicare affordability. Of those, 53% were related to Part B premiums and 43% were related to Part D drug costs. And these calls were not just from low-income people; 44% of callers did not qualify for Extra Help due to the program’s low asset and income limits. One beneficiary who was scheduled to undergo a kidney transplant needed to take a specialty antiviral medication for six months after the transplant at a cost of $2,500 per month. He did not qualify for Extra Help and could not appeal. Medicare Rights is working to improve the affordability of prescription drugs for people on Medicare, including allowing “tiering exceptions” for drugs on a Part D plan’s specialty tier.

The report supports our mission to educate financial advisors on Medicare enrollment rules in order to save their clients some of these headaches. In addition to helping clients enroll in Medicare on time, we encourage you to be aware of Medicare Advantage pitfalls, particularly with regard to the narrowing of provider networks and lack of communication when an out-of-network doctor steps in to treat a patient at an in-network facility. If clients lack access to a good, robust Medicare Advantage plan with an extensive provider network, you might steer them toward Original Medicare with a comprehensive Medigap plan (F or G). For those who insist upon enrolling in a Medicare Advantage plan, alert them to some of these network pitfalls and advise them to confirm that they are being treated by an in-network doctor at the time of treatment (assuming they are conscious and not bleeding).

Two Documents Your Estate Plan Must Have Now!!!

Power of attorney

LegalZoom defines power of attorney (POA) as, “a document you can use to appoint someone to make decisions on your behalf. The person you designate is called an ‘attorney-in-fact.’” There are three main elements for a valid POA: (1) the person signing the document (the principal) must be mentally competent and acting without undue pressure from anyone; (2) the document must contain the date of execution; and (3) the signature must be notarized or be witnessed by two unrelated adults. State laws vary, so see an attorney for advice.

There are several important reasons for having a POA. For one, if there is no designated agent, the state may step in and appoint a guardian, a decision over which the family will have no say. Also, it is critical to have a financial overseer if and when a senior’s mental health declines.

In practice, a POA is very flexible, suiting the needs of each individual family. It can be “special” or “limited,” meaning that authority is granted only for a set period of time or for a particular transaction. No other powers are given. Conversely, a durable power of attorney allows an agent to manage all the affairs of the principal for any length of time, although it does expire at the time of death. A springing POA goes into effect only when a specific, predetermined event occurs, i.e., the principal becomes incapacitated. It can be durable or limited. Also, the agent can be granted as many or as few powers as the principal wants.

Caution needs to be taken when choosing an agent, especially in regard to financial matters. Dishonest agents have used POAs as opportunities to steal from unsuspecting seniors. We encourage you and your loved ones to sign a POA.

In fact, it might be you who is chosen to take on the role of attorney-in-fact. Caring.com, an online resource for caregivers, offers the following tips for preparing to become a POA:

  • Create a caregiving team—people who can advise you and be the resource you need to make good decisions.
  • Consider all ramifications of a decision, not giving in to what others may think or pressure from doctors or professionals. Choose what is best for your family member.
  • Do some research on accounting, medical terminology, and counseling.
  • Give yourself permission to make mistakes.
  • Know the current state of affairs for the person you will be representing, both financially and medically.
  • Establish a cordial relationship with the rest of the family.

Health care directive

A health care directive is also referred to as a medical power of attorney or an advance directive. LegalZoom defines a health care directive as a “document that explains a person’s health care preferences when he or she is unable to make those choice for him or herself.” Some directives may designate a health care agent, a person given the authority to make medical decisions on the principal’s behalf.

A health care directive is not the same as a living will. A living will is limited to situations when the principal is terminally ill or permanently unconscious. It does not apply to any other situations where medical decisions might need to be made. However, a living will can be useful to give some guidance to the health care agent.

WebMD gives these guidelines about choosing, or helping a parent choose, a health care agent:

  • Choose someone you trust, who knows you well and who can handle stress and emotional turmoil.
  • Consider medical issues and your care options, then take the time to put them in an advance directive and/or discuss your values and preferences with the agent.
  • Don’t assume that a child or spouse knows what you want. Talk openly about your wishes.
  • It’s not possible to discuss every situation that would arise, so choose someone who knows what is important to you.
  • Check with your state about required documents. Make sure you complete everything.
  • Tell your family, doctors, and anyone else involved in medical care who your agent is.

We all hope our loved ones remain healthy and capable as long as possible, but the reality is that they will one day become compromised at some level. Be assure that getting your elders to choose now who will make decisions when they cannot is actually the best way to preserve their independence.